Policies for expanding family planning coverage: lessons from five successful countries.

Background: Enhancing the design of family planning interventions is crucial for promoting gender equality and improving maternal and child health outcomes. We identified, critically appraised, and synthesized policies and strategies from five selected countries that successfully increased family planning coverage. Methods: We conducted a policy analysis through a scoping review and document search, focusing on documents published from 1950 to 2023 that examined or assessed policies aimed at enhancing family planning coverage in Brazil, Ecuador, Egypt, Ethiopia, and Rwanda. A search was conducted through PubMed, SCOPUS, and Web of Science. Government documents and conference proceedings were also critically analyzed. National health surveys were analyzed to estimate time trends in demand for family planning satisfied by modern methods (mDFPS) at the national level and by wealth. Changes in the method mix were also assessed. The findings of the studies were presented in a narrative synthesis. Findings: We selected 231 studies, in which 196 policies were identified. All countries started to endorse family planning in the 1960s, with the number of identified policies ranging between 21 in Ecuador and 52 in Ethiopia. Most of the policies exclusively targeted women and were related to supplying contraceptives and enhancing the quality of the services. Little focus was found on monitoring and evaluation of the policies implemented. Conclusion: Among the five selected countries, a multitude of actions were happening simultaneously, each with its own vigor and enthusiasm. Our findings highlight that these five countries were successful in increasing family planning coverage by implementing broader multi-sectoral policies and considering the diverse needs of the population, as well as the specific contextual factors at play. Successful policies require a nuanced consideration of how these policies align with each culture's framework, recognizing that both sociocultural norms and the impact of past public policies shape the current state of family planning.

Towards a better tomorrow: addressing intersectional gender power relations to eradicate inequities in maternal health.

An equity lens to maternal health has typically focused on assessing the differences in coverage and use of healthcare services and critical interventions. While this approach is important, we argue that healthcare experiences, dignity, rights, justice, and well-being are fundamental components of high quality and person-centred maternal healthcare that must also be considered. Looking at differences across one dimension alone does not reflect how fundamental drivers of maternal health inequities-including racism, ethnic or caste-based discrimination, and gendered power relations-operate. In this paper, we describe how using an intersectionality approach to maternal health can illuminate how power and privilege (and conversely oppression and exclusion) intersect and drive inequities. We present an intersectionality-informed analysis on antenatal care quality to illustrate the advantages of this approach, and what is lost in its absence. We reviewed and mapped equity-informed interventions in maternal health to existing literature to identify opportunities for improvement and areas for innovation. The gaps and opportunities identified were then synthesised to propose recommendations on how to apply an intersectionality lens to maternal health research, programmes, and policies.

Identifying and Characterizing the Poorest Urban Population Using National Household Surveys in 38 Cities in Sub-Saharan Africa.

Identifying and classifying poor and rich groups in cities depends on several factors. Using data from available nationally representative surveys from 38 sub-Saharan African countries, we aimed to identify, through different poverty classifications, the best classification in urban and large city contexts. Additionally, we characterized the poor and rich groups in terms of living standards and schooling. We relied on absolute and relative measures in the identification process. For absolute ones, we selected people living below the poverty line, socioeconomic deprivation status and the UN-Habitat slum definition. We used different cut-off points for relative measures based on wealth distribution: 30%, 40%, 50%, and 60%. We analyzed all these measures according to the absence of electricity, improved drinking water and sanitation facilities, the proportion of children out-of-school, and any household member aged 10 or more with less than 6 years of education. We used the sample size, the gap between the poorest and richest groups, and the observed agreement between absolute and relative measures to identify the best measure. The best classification was based on 40% of the wealth since it has good discriminatory power between groups and median observed agreement higher than 60% in all selected cities. Using this measure, the median prevalence of absence of improved sanitation facilities was 82% among the poorer, and this indicator presented the highest inequalities. Educational indicators presented the lower prevalence and inequalities. Luanda, Ouagadougou, and N'Djaména were considered the worst performers, while Lagos, Douala, and Nairobi were the best performers. The higher the human development index, the lower the observed inequalities. When analyzing cities using nationally representative surveys, we recommend using the relative measure of 40% of wealth to characterize the poorest group. This classification presented large gaps in the selected outcomes and good agreement with absolute measures.

Coverage, Trends, and Inequalities of Maternal, Newborn, and Child Health Indicators among the Poor and Non-Poor in the Most Populous Cities from 38 Sub-Saharan African Countries.

Rapid urbanization is likely to be associated with suboptimal access to essential health services. This is especially true in cities from sub-Saharan Africa (SSA), where urbanization is outpacing improvements in infrastructure. We assessed the current situation in regard to several markers of maternal, newborn, and child health, including indicators of coverage of health interventions (demand for family planning satisfied with modern methods, at least four antenatal care visits (ANC4+), institutional birth, and three doses of DPT vaccine[diphtheria, pertussis and tetanus]) and health status (stunting in children under 5 years, neonatal and under-5 mortality rates) among the poor and non-poor in the most populous cities from 38 SSA countries. We analyzed 136 population-based surveys (year range 2000-2019), contrasting the poorest 40% of households (referred to as poor) with the richest 60% (non-poor). Coverage in the most recent survey was higher for the city non-poor compared to the poor for all interventions in virtually all cities, with the largest median gap observed for ANC4+ (13.5 percentage points higher for the non-poor). Stunting, neonatal, and under-5 mortality rates were higher among the poor (7.6 percentage points, 21.2 and 10.3 deaths per 1000 live births, respectively). The gaps in coverage between the two groups were reducing, except for ANC4, with similar median average annual rate of change in both groups. Similar rates of change were also observed for stunting and the mortality indicators. Continuation of these positive trends is needed to eliminate inequalities in essential health services and child survival in SSA cities.

Measures of women's empowerment based on individual-level data: a literature review with a focus on the methodological approaches.

Background: Quantifying women's empowerment has become the focus of attention of many international organizations and scholars. We aimed to describe quantitative indicators of women's empowerment that are based on individual-level data. Methods: In this scoping review, we searched PubMed, Scopus, Web of Science, Science Direct, Google, and Google Scholar for publications describing the operationalization of measures of women's empowerment. Results: We identified 36 studies published since 2004, half of them since 2019, and most from low- and middle-income countries. Twelve studies were based on data from the Demographic and Health Surveys and used 56 different variables from the questionnaires (ranging from one to 25 per study) to measure the overall empowerment of women 15-49 years. One study focused on rural women, two included married and unmarried women, and one analyzed the couple's responses. Factor analysis and principal component analysis were the most common approaches used. Among the 24 studies based on other surveys, ten analyzed overall empowerment, while the others addressed sexual and reproductive health (4 studies), agriculture (3) and livestock (1), water and sanitation (2), nutrition (2), agency (1), and psychological empowerment (1). These measures were mainly based on data from single countries and factor analysis was the most frequently analytical method used. We observed a diversity of indicator definitions and domains and a lack of consensus in terms of what the proposed indicators measure. Conclusion: The proposed women's empowerment indicators represent an advance in the field of gender and development monitoring. However, the empowerment definitions used vary widely in concept and in the domains/dimensions considered, which, in turn influence or are influenced by the adopted methodologies. It remains a challenge to find a balance between the need for a measure suitable for comparisons across populations and over time and the incorporation of country-specific elements.

Recent trends in maternal and child health inequalities in Latin America and the Caribbean: analysis of repeated national surveys.

BACKGROUND: Although most Latin American and the Caribbean (LAC) countries made important progress in maternal and child health indicators from the 1990s up to 2010, little is known about such progress in the last decade. This study aims at documenting progress for each country as a whole, and to assess how within-country socioeconomic inequalities are evolving over time. METHODS: We identified LAC countries for which a national survey was available between 2011-2015 and a second comparable survey in 2018-2020. These included Argentina, Costa Rica, Cuba, the Dominican Republic, Guyana, Honduras, Peru, and Suriname. The 16 surveys included in the analysis collected nationally representative data on 221,989 women and 152,983 children using multistage sampling. Twelve health-related outcomes were studied, seven of which related to intervention coverage: the composite coverage index, demand for family planning satisfied with modern methods, antenatal care (four or more visits and eight or more visits), skilled attendant at birth, postnatal care for the mother and full immunization coverage. Five additional impact indicators were also investigated: stunting prevalence among under-five children, tobacco use by women, adolescent fertility rate, and under-five and neonatal mortality rates. For each of these indicators, average annual relative change rates were calculated between the baseline and endline national level estimates, and changes in socioeconomic inequalities over time were assessed using the slope index of inequality. RESULTS: Progress over time and the magnitude of inequalities varied according to country and indicator. For countries and indicators where baseline levels were high, as Argentina, Costa Rica and Cuba, progress was slow and inequalities small for most indicators. Countries that still have room for improvements, such as Guyana, Honduras, Peru and Suriname, showed faster progress for some but not all indicators, although also had wider inequalities. Among the countries studied, Peru was the top performer in terms of increasing coverage and reducing inequalities over time, followed by Honduras. Declines in family planning and immunization coverage were observed in some countries, and the widest inequalities were present for adolescent fertility and antenatal care coverage with eight or more visits. CONCLUSIONS: Although LAC countries are well placed in terms of current levels of health indicators compared to most low- and middle-income countries, important inequalities remain, and reversals are being observed in some areas. More targeted efforts and actions are needed in order to leave no one behind. Monitoring progress with an equity lens is essential, but this will require further investment in conducting surveys routinely.

Trends and inequities in adolescent childbearing in Latin American and Caribbean countries across generations and over time: a population-based study.

BACKGROUND: Latin America and the Caribbean present the second highest adolescent fertility rate in the world, only after sub-Saharan Africa, and have reached the third position globally in the incidence of motherhood in adolescence. We aimed to explore trends and inequities in adolescent childbearing in the region. METHODS: We used nationally representative household surveys from Latin American and Caribbean countries to address trends in early childbearing (proportion of women having their first livebirth before age 18 years) over generations and in adolescent fertility rates (AFRs; livebirths per 1000 women aged 15-19 years) over time. For early childbearing, we analysed the most recent survey conducted since 2010 from 21 countries (2010-20); for AFR, we analysed nine countries with two or more surveys, with the most recent being conducted from 2010 onwards. For both indicators, variance-weighted least-square regression was used to estimate the average absolute changes (AACs) at the national level and by wealth (bottom 40% vs top 60%), urban versus rural residence, and ethnicity. FINDINGS: Among 21 countries studied, we noted a decrease in early childbearing along generations in 13 of them, with declines varying from -0·6 percentage points (95% CI -1·1 to -0·1) in Haiti to -2·7 percentage points (-4·0 to -1·4) in Saint Lucia. We observed increases over generations in Colombia (1·2 percentage points [0·8 to 1·5]) and Mexico (1·3 percentage points [0·5 to 2·0]) and no changes in Bolivia and Honduras. The fastest early childbearing decline occurred among rural women, whereas no clear pattern was observed for wealth groups. Decreasing estimates from oldest to youngest generations were found among Afro-descendants and non-Afro-descendant and non-indigenous groups, but results were mixed for indigenous people. All nine countries with data for AFR presented reductions over time (-0·7 to -6·5 births per 1000 women per year), with the steepest declines observed in Ecuador, Guyana, Guatemala, and the Dominican Republic. In general, adolescents in rural areas and the poorest adolescents had the largest reductions in AFR. If current trends persist, by 2030 most countries will present AFR values ranging between 45 and 89 births per 1000 women, with notable wealth-related inequalities. INTERPRETATION: Our results indicate a reduction in AFR in Latin American and Caribbean countries that was not necessarily accompanied by a decrease in early childbearing overall. Large inequalities both between countries and within countries were observed, with no clear reduction over time. Understanding trends in adolescent childbearing and its determinants is essential for planning and designing programmes to ensure the desired reductions in rates and gaps across population subgroups. FUNDING: PAHO, Bill & Melinda Gates Foundation, and Wellcome Trust. TRANSLATIONS: For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Inequalities in Immunization against Maternal and Neonatal Tetanus: A Cross-Sectional Analysis of Protection at Birth Coverage Using Household Health Survey Data from 76 Countries.

Substantial progress in maternal and neonatal tetanus elimination has been made in the past 40 years, with dramatic reductions in neonatal tetanus incidence and mortality. However, twelve countries have still not achieved maternal and neonatal tetanus elimination, and many countries that have achieved elimination do not meet key sustainability thresholds to ensure long-lasting elimination. As maternal and neonatal tetanus is a vaccine-preventable disease (with coverage of the infant conferred by maternal immunization during and prior to pregnancy), maternal tetanus immunization coverage is a key metric for monitoring progress towards, equity in, and sustainability of tetanus elimination. In this study, we examine inequalities in tetanus protection at birth, a measure of maternal immunization coverage, across 76 countries and four dimensions of inequality via disaggregated data and summary measures of inequality. We find that substantial inequalities in coverage exist for wealth (with lower coverage among poorer wealth quintiles), maternal age (with lower coverage among younger mothers), maternal education (with lower coverage among less educated mothers), and place of residence (with lower coverage in rural areas). Inequalities existed for all dimensions across low- and lower-middle-income countries, and across maternal education and place of residence across upper-middle-income countries. Though global coverage changed little over the time period 2001-2020, this obscured substantial heterogeneity across countries. Notably, several countries had substantial increases in coverage accompanied by decreases in inequality, highlighting the need for equity considerations in maternal and neonatal tetanus elimination and sustainability efforts.

Time trends in ethnic inequalities in child health and nutrition: analysis of 59 low and middle-income countries.

BACKGROUND: Although ethnicity is a key social determinant of health, there are no global analyses aimed at identifying countries that succeeded in reducing ethnic gaps in child health and nutrition. METHODS: We identified 59 low and middle-income countries with at least two surveys since 2010 providing information on ethnicity or language and on three outcomes: under-five mortality, child stunting prevalence and a composite index (CCI) based on coverage with eight maternal and child health interventions. Firstly, we calculated population-weighted and unweighted measures of inequality among ethnic or language groups within each country. These included the mean difference from the overall national mean (absolute inequality), mean ratio relative to the overall mean (relative inequality), and the difference and ratio between the best- and worst-performing ethnic groups. Second, we examined annual changes in these measures in terms of annual absolute and relative changes. Thirdly, we compared trends for each of the three outcome indicators and identified exemplar countries with marked progress in reducing inequalities. RESULTS: For each outcome indicator, annual changes in summary measures tended to show moderate (Pearson correlation coefficients of 0.4 to 0.69) or strong correlations (0.7 or higher) among themselves, and we thus focused on four of the 12 measures: absolute and relative annual changes in mean differences and ratios from the overall national mean. On average, absolute ethnic or language group inequalities tended to decline slightly for the three outcomes, and relative inequality declined for stunting and CCI, but increased for mortality. Correlations for annual trends across the three outcomes were inconsistent, with several countries showing progress in terms of one outcome but not in others. Togo and Uganda showed with the most consistent progress in reducing inequality, whereas the worst performers were Nigeria, Moldova, Kyrgyzstan, Sao Tome and Principe, and Burkina Faso. CONCLUSIONS: Although measures of annual changes in ethnic or language group inequalities in child health were consistently correlated within each outcome, analyses of such inequalities should rely upon multiple measures. Countries showing progress in one child health outcome did not necessarily show improvements in the remaining outcomes. In-depth analyses at country level are needed to understand the drivers of success in reducing ethnic gaps.

Sociodemographic inequalities in vegetables, fruits, and animal source foods consumption in children aged 6-23 months from 91 LMIC.

Introduction: No multi-country analysis described patterns and inequalities for the brand-new feeding indicators proposed by WHO/UNICEF: zero consumption of vegetables and fruits (ZVF) and consumption of eggs and/or flesh (EFF). Our aim was to describe patterns in the prevalence and social inequalities of ZVF and EFF among children aged 6-23 months in low-and middle-income countries. Methods: Data from nationally representative surveys (2010-2019) in 91 low-and middle-income countries were used to investigate within-country disparities in ZVF and EFF by place of residence, wealth quintiles, child sex and child age. The slope index of inequality was used to assess socioeconomic inequalities. Analyses were also pooled by World Bank income groups. Results: The prevalence of ZVF was 44.8% and it was lowest in children from upper-middle income countries, from urban areas, and those 18-23 months. The slope index of inequality showed that socioeconomic inequalities in the prevalence of ZVF were higher among poor children in comparison to richest children (mean SII = -15.3; 95%CI: -18.5; -12.1). Overall, 42.1% of children consumed egg and/or flesh foods. Being a favorable indicator, findings for EFF were generally in the opposite direction than for ZVF. The prevalence was highest in children from upper-middle income countries, from urban areas, and those 18-23 months of age. The slope index of inequality showed pro-rich patterns in most countries (mean SII = 15.4; 95%CI: 12.2; 18.6). Discussion: Our findings demonstrate that inequalities exist in terms of household wealth, place of residence, and age of the child in the prevalence of the new complementary feeding indicators. Moreover, children from low-and lower-middle countries had the lowest consumption of fruits, vegetables, eggs, and flesh foods. Such findings provide new insights towards effective approaches to tackle the malnutrition burden through optimal feeding practices.

The role of gender inequality and health expenditure on the coverage of demand for family planning satisfied by modern contraceptives: a multilevel analysis of cross-sectional studies in 14 LAC countries.

Background: Despite international efforts to improve reproductive health indicators, little attention is paid to the contributions of contextual factors to modern contraceptive coverage, especially in the Latin America and the Caribbean (LAC) region. This study aimed to identify the association between country-level Gender Inequality and Health Expenditure with demand for family planning satisfied by modern contraceptive methods (DFPSm) in Latin American sexually active women. Methods: Our analyses included data from the most recent (post-2010) Demographic and Health Survey or Multiple Indicator Cluster Survey from 14 LAC countries. Descriptive analyses and multilevel logistic regressions were performed. Six individual-level factors were included. The effect of the country-level factors Gender Inequality Index (GII) and Current Health Expenditure on DFPSm was investigated. Findings: DFPSm ranged from 41.8% (95% CI: 40.2-43.5) in Haiti to 85.6% (95% CI: 84.9-86.3) in Colombia, with an overall median coverage of 77.8%. A direct association between the odds of DFPSm and woman's education, wealth index, and the number of children was identified. Women from countries in the highest GII tertile were less likely (OR: 0.32, 95% CI: 0.13-0.76) to have DFPSm than those living in countries in the lowest tertile. Interpretation: Understanding the contribution of country-level factors to modern contraception may allow macro-level actions focused on the population's reproductive needs. In this sense, country-level gender inequalities play an important role, as well as individual factors such as wealth and education. Funding: Bill and Melinda Gates Foundation and Associação Brasileira de Saúde Coletiva (ABRASCO).

What are the sources of contraceptives for married and unmarried adolescents: Health services or friends? Analysis of 59 low- and middle-income countries.

Background: Despite the efforts to promote universal coverage for family planning, inequalities are still high in several countries. Our aim was to identify which sources of contraceptives women mostly rely on in low- and middle-income countries (LMICs). We also explored the different sources according to age and marital status. Methods: We used data from national health surveys carried out in 59 LMICs since 2010. Among all sexually active women at reproductive age, we explored inequalities in demand for family planning satisfied by modern methods (mDFPS) and in the source of modern contraceptives according to women's age, classified as: 15-19, 20-34, or 35-49 years of age. Among adolescents, mDFPS and source of method were explored by marital status, classified as married or in union and not married nor in a union. Results: mDFPS was lower among adolescents than among adult women in 28 of the 59 countries. The lowest levels of mDFPS among adolescents were identified in Albania (6.1%) and Chad (8.2%). According to adolescents' marital status, the pattern of inequalities in mDFPS varied widely between regions, with married and unmarried adolescents showing similar levels of coverage in Latin America and the Caribbean, higher coverage among unmarried adolescents in Africa, and lower coverage among unmarried adolescents in Asia. Public and private health services were the main sources, with a lower share of the public sector among adolescents in almost all countries. The proportion of adolescents who obtained their contraceptives in the public sector was lower among unmarried girls than married ones in 31 of the 38 countries with data. Friends or relatives were a more significant source of contraceptives among unmarried compared to married adolescents in all regions. Conclusions: Our findings indicate lower levels of mDFPS and lower use of the public sector by adolescents, especially unmarried girls. More attention is needed to provide high-quality and affordable family planning services for adolescents, especially for those who are not married.

Cross-National Associations between Age at Marriage and Intimate Partner Violence among Young Women: An Analysis of Demographic and Health Surveys from 48 Countries.

We estimated the associations between age at first marriage and recent intimate partner violence (IPV) among women young women aged 20-24 years using data from demographic and health surveys (DHS) conducted at 48 low- and middle-income countries (LMICs). We fitted a multilevel logistic regression model controlling for sociodemographic covariates. Our pooled analyses revealed that age at marriage is strongly associated with past year IPV in a non-linear way, with steep reductions in violence when young women marry after age 15 and a continued decline in IPV for every year marriage is delayed up to age 24. The risk of physical IPV was 3.3 times higher among women married at age 15 (24.4%, 95% CI 19.7; 29.2%) compared to young women married at age 24 (7.5%, 95% CI 5.8; 9.2%). For sexual IPV, girls married at 15 had 2.2 times higher risk compared to those married at 24 (7.5%, 95% CI 5.6; 9.5% vs. 3.4%, 95% CI 2.7; 4.2%, respectively). For psychological IPV, the relative risk was 3.4 for the same comparison (married at 15: 20.1%, 95% CI 14.6; married at 24: 25.5% vs. 6.0%, 95% CI 3.4; 8.6%). Country specific analyses showed that, age at marriage was negatively associated with physical and psychological IPV in nearly half of the countries (n/48) and with sexual IPV in ten countries. Our findings underscore the importance of integrating violence prevention and response interventions into efforts to prevent child marriage, as well as the health, educations and social services young women access.

Breastfeeding: crucially important, but increasingly challenged in a market-driven world.

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

Geographic inequalities in health intervention coverage - mapping the composite coverage index in Peru using geospatial modelling.

BACKGROUND: The composite coverage index (CCI) provides an integrated perspective towards universal health coverage in the context of reproductive, maternal, newborn and child health. Given the sample design of most household surveys does not provide coverage estimates below the first administrative level, approaches for achieving more granular estimates are needed. We used a model-based geostatistical approach to estimate the CCI at multiple resolutions in Peru. METHODS: We generated estimates for the eight indicators on which the CCI is based for the departments, provinces, and areas of 5 × 5 km of Peru using data from two national household surveys carried out in 2018 and 2019 plus geospatial covariates. Bayesian geostatistical models were fit using the INLA-SPDE approach. We assessed model fit using cross-validation at the survey cluster level and by comparing modelled and direct survey estimates at the department-level. RESULTS: CCI coverage in the provinces along the coast was consistently higher than in the remainder of the country. Jungle areas in the north and east presented the lowest coverage levels and the largest gaps between and within provinces. The greatest inequalities were found, unsurprisingly, in the largest provinces where populations are scattered in jungle territory and are difficult to reach. CONCLUSIONS: Our study highlighted provinces with high levels of inequality in CCI coverage indicating areas, mostly low-populated jungle areas, where more attention is needed. We also uncovered other areas, such as the border with Bolivia, where coverage is lower than the coastal provinces and should receive increased efforts. More generally, our results make the case for high-resolution estimates to unveil geographic inequities otherwise hidden by the usual levels of survey representativeness.

Religious affiliation as a driver of immunization coverage: Analyses of zero-dose vaccine prevalence in 66 low- and middle-income countries.

Background: The literature on the association between religion and immunization coverage is scant, mostly consisting of single-country studies. Analyses in low and middle-income countries (LMICs) to assess whether the proportions of zero-dose children vary according to religion remains necessary to better understand non-socioeconomic immunization barriers and to inform interventions that target zero-dose children. Methods: We included 66 LMICs with standardized national surveys carried out since 2010, with information on religion and vaccination. The proportion of children who failed to receive any doses of a diphtheria-pertussis-tetanus (DPT) containing vaccine - a proxy for no access to routine vaccination or "zero-dose" status - was the outcome. Differences among religious groups were assessed using a test for heterogeneity. Additional analyses were performed controlling for the fixed effect of country, household wealth, maternal education, and urban-rural residence to assess associations between religion and immunization. Findings: In 27 countries there was significant heterogeneity in no-DPT prevalence according to religion. Pooled analyses adjusted for wealth, maternal education, and area of residence showed that Muslim children had 76% higher no-DPT prevalence than Christian children. Children from the majority religion in each country tended to have lower no-DPT prevalence than the rest of the population except in Muslim-majority countries. Interpretation: Analyses of gaps in coverage according to religion are relevant to renewing efforts to reach groups that are being left behind, with an important role in the reduction of zero-dose children.

Inequalities in the health, nutrition, and wellbeing of Afrodescendant women and children: A cross-sectional analysis of ten Latin American and Caribbean countries.

Background: Afrodescendants are systematically affected by discrimination in the Americas and few multi-country studies addressed ethnic inequalities in health and wellbeing in the region. We aimed to investigate gaps in coverage of key health outcomes and socioeconomic inequalities between Afrodescendants and non-Afrodescendants populations in Latin American and Caribbean countries. Methods: Using national household surveys (2011-2019) from ten countries, we analyzed absolute inequalities between Afrodescendants and a comparison group that includes non-Afrodescendants and non-Indigenous individuals (henceforth non-Afrodescendants) across 17 indicators in the continuum of reproductive, maternal, newborn, child, and adolescent health. These include indicators of family planning, antenatal care, delivery assistance, child nutrition, immunization coverage, child protection, access to improved water, sanitation and hygiene, adolescent fertility, and early childhood mortality. Inequalities between country-specific subgroups of Afrodescendants were also explored. The slope index of inequality was used to assess wealth-based inequalities within each ethnic group. Findings: Afrodescendants represented from 2·8% (Honduras) to 59·1% (Brazil) of the national samples. Of the 128 combinations of country and indicators with data, Afrodescendants fared worse in 78 (of which 33 were significant) and performed better in 50 (15 significant). More systematic disadvantages for Afrodescendants were found for demand for family planning satisfied, early marriage, and household handwashing and sanitation facilities. In contrast, Afrodescendants tended to present lower c-section rates and lower stunting prevalence. Honduras was the only country where Afrodescendants performed better than non-Afrodescendants in several indicators. Wealth gaps among Afrodescendants were wider than those observed for non-Afrodescendants for most indicators and across all countries. Interpretation: Gaps in health outcomes between Afrodescendants and non-Afrodescendants were observed in most countries, with more frequent disadvantages for the former although, in many cases, the gaps were reversed. Wealth inequalities within Afrodescendants tended to be wider than for non-Afrodescendants. Funding: Pan American Health Organization, Bill and Melinda Gates Foundation, and the Wellcome Trust.

Birth registration coverage according to the sex of the head of household: an analysis of national surveys from 93 low- and middle-income countries.

BACKGROUND: Within-country inequalities in birth registration coverage (BRC) have been documented according to wealth, place of residence and other household characteristics. We investigated whether sex of the head of household was associated with BRC. METHODS: Using data from nationally-representative surveys (Demographic and Health Survey or Multiple Indicator Cluster Survey) from 93 low and middle-income countries (LMICs) carried out in 2010 or later, we developed a typology including three main types of households: male-headed (MHH) and female-led with or without an adult male resident. Using Poisson regression, we compared BRC for children aged less than 12 months living the three types of households within each country, and then pooled results for all countries. Analyses were also adjusted for household wealth quintiles, maternal education and urban-rural residence. RESULTS: BRC ranged from 2.2% Ethiopia to 100% in Thailand (median 79%) while the proportion of MHH ranged from 52.1% in Ukraine to 98.3% in Afghanistan (median 72.9%). In most countries the proportion of poor families was highest in FHH (no male) and lowest in FHH (any male), with MHH occupying an intermediate position. Of the 93 countries, in the adjusted analyses, FHH (no male) had significantly higher BRC than MHH in 13 countries, while in eight countries the opposite trend was observed. The pooled analyses showed t BRC ratios of 1.01 (95% CI: 1.00; 1.01) for FHH (any male) relative to MHH, and also 1.01 (95% CI: 1.00; 1.01) for FHH (no male) relative to MHH. These analyses also showed a high degree of heterogeneity among countries. CONCLUSION: Sex of the head of household was not consistently associated with BRC in the pooled analyses but noteworthy differences in different directions were found in specific countries. Formal and informal benefits to FHH (no male), as well as women's ability to allocate household resources to their children in FHH, may explain why this vulnerable group has managed to offset a potential disadvantage to their children.

Exposure of Zero-Dose Children to Multiple Deprivation: Analyses of Data from 80 Low- and Middle-Income Countries.

The concept of multiple deprivation recognizes that the same individuals, households, and communities are often exposed to several forms of scarcity. We assessed whether lack of immunization is also associated with nutritional, environmental, and educational outcomes. We analyzed data from nationally representative surveys from 80 low- and middle-income countries with information on no-DPT (children aged 12-23 months without any doses of a diphtheria, pertussis and tetanus containing vaccine), stunting, wasting, maternal education and use of contraception, improved water and sanitation, and long-lasting insecticidal nets. Analyses of how these characteristics overlap were performed at individual and ecological levels. Principal component analyses (PCA) provided additional information on indicator clustering. In virtually all analyses, no-DPT children were significantly more likely to be exposed to the other markers for deprivation. The strongest, most consistent associations were found with maternal education, water, and sanitation, while the weakest associations were found for wasting and bed nets. No-DPT prevalence reached 46.1% in the most deprived quintile from first PCA component derived from deprivation indicators. All children were immunized in the two least deprived quintiles of the component. Our analyses provide strong support for the hypothesis that unimmunized children are also affected by other forms of deprivation.

[Use of anti-bacterial agents in pregnant women before and after regulation in Brazil: Pelotas (Brazil) birth cohorts of 2004 and 2015]. / Uso de antibacterianos em gestantes antes e após regulamentação no Brasil: coortes de nascimentos de Pelotas, Rio Grande do Sul, de 2004 e 2015.

Indiscriminate use of anti-bacterial agents during pregnancy can increase antimicrobial resistance and endanger both the mother's and the children's health. Currently, Brazil has the Collegiate Directive Resolution n. 20/2011, which controls prescription and dispensation of anti-bacterial agents. Given this scenario, this study compared the use of anti-bacterial agents by pregnant women participating in the 2004 and 2015 Pelotas (Brazil) birth cohorts, in Rio Grande do Sul, Brazil, considering the regulation issued between the two cohorts. Data were collected in the perinatal period of the two studies. The main outcome was the use of anti-bacterial agents during pregnancy. Prevalence scans were described based on independent variables and differences in percentage points (p.p.) between the two cohorts. The prevalence of anti-bacterial use was 41.9% (95%CI: 40.4; 43.3) in 2004 and 39.2% (95%CI: 37.7; 40.6) in 2015. Considering the pregnant women who reported having infection during pregnancy, a greater reduction in use was observed in 2015, when compared to 2004, in poor women (-15.4p.p., 95%CI: 9.59; 21.20) and in those who had less consultations (-17.1p.p., 95%CI: 2.81; 31.36). Considering total medications, the proportion of anti-bacterial used dropped from 20.6% (95%CI: 19.9; 21.4) in 2004 to 12.6% (95%CI: 12.1; 13.1) in 2015. The reductions found in both the prevalence of use and the proportion of anti-bacterial agents over total medications used may be a reflection of the regulatory policy implemented in 2011.

A utilização indiscriminada de antibacterianos no período gestacional pode aumentar a resistência antimicrobiana e colocar em risco a saúde da gestante e da criança. Atualmente, está em vigência no Brasil a Resolução da Diretoria Colegiada nº 20/2011, que controla a prescrição e fornecimento de antibacterianos. O objetivo deste estudo foi comparar o uso de antibacterianos pelas gestantes participantes das coortes de nascimentos de Pelotas, Rio Grande do Sul, Brasil, de 2004 e 2015, considerando a regulamentação implementada entre as duas coortes. Foram utilizados dados coletados no período perinatal dos dois estudos. O desfecho principal foi o uso de antibacterianos na gestação. As prevalências de uso foram descritas a partir de variáveis independentes e diferenças em pontos percentuais (p.p.) entre as duas coortes. A prevalência do uso de antibacterianos foi de 41,9% (IC95%: 40,4; 43,3) em 2004 e 39,2% (IC95%: 37,7; 40,6) em 2015. Considerando-se as gestantes que relataram ter infecção durante a gestação, observou-se maior redução de uso em 2015, quando comparado a 2004, nas gestantes mais pobres (-15,4p.p., IC95%: 9,59; 21,20) e naquelas que foram a menos consultas (-17,1p.p., IC95%: 2,81; 31,36). Houve redução na proporção de antibacterianos usados, considerando o total de medicamentos de 20,6% (IC95%: 19,9; 21,4) em 2004 para 12,6% (IC95%: 12,1; 13,1) em 2015. As reduções encontradas, tanto nas prevalências de uso quanto na proporção dos antibacterianos sobre o total de medicamentos utilizados, podem ser reflexo da política de regulamentação implementada em 2011.

El uso indiscriminado de antibacterianos durante el embarazo puede aumentar la resistencia a los antimicrobianos y poner en riesgo la salud de la gestante y del niño. Actualmente, está vigente en Brasil la Resolución de la Dirección Colegiada nº 20/2011, que controla la prescripción y dispensación de antibacterianos. El objetivo de este estudio fue comparar el uso de antibacterianos por gestantes participantes de las cohortes de nacimientos de Pelotas, Rio Grande do Sul, Brasil, del 2004 y del 2015, considerando la regulación implementada entre las dos cohortes. Se utilizaron los datos recopilados en el período perinatal de los dos estudios. El resultado principal fue el uso de antibacterianos durante el embarazo. Las prevalencias de uso se describieron con base en las variables independientes y diferencias en puntos porcentuales (p.p.) entre las dos cohortes. La prevalencia de uso de antibacterianos fue del 41,9% (IC95%: 40,4; 43,3) en el 2004 y del 39,2% (IC95%: 37,7; 40,6) en el 2015. Teniendo en cuenta que las gestantes que reportaron haber tenido infección durante el embarazo, hubo una mayor reducción de uso en el 2015, en comparación con el 2004, en las gestantes más pobres (-15,4p.p., IC95%: 9,59; 21,20) y en las que consultaron menos (-17,1p.p., IC95% 2,81;31,36). Hubo una reducción en la proporción de antibacterianos usados, considerando la cantidad total de medicamentos del 20,6% (IC95%: 19,9; 21,4) en el 2004 al 12,6% (IC95%: 12,1; 13,1) en el 2015. Las reducciones encontradas, tanto en las prevalencias de uso como en la proporción de antibacterianos sobre la cantidad total de medicamentos utilizados, pueden ser reflejo de la política regulatoria implementada en el 2011.